Optimizing Nutrition Care for Pressure Injuries

in Hospitalized Patients

Sandra W. Citty,1,* Linda J. Cowan,2 Zandra Wingfield,1

and Joyce Stechmiller3
1
Department of Family, Community and Health System Science, University of Florida College of Nursing,
Gainesville, Florida.
2
Nursing Service and Research, Tampa VA Center of Innovation for Disability and Rehabilitation
Research (CINDRR), Tampa, Florida.
3
Department of Behavioral Nursing Science, University of Florida College of Nursing, Gainesville, Florida.

Significance: It is estimated that up to 50% of hospitalized patients are mal-

nourished. Malnutrition can lead to longer hospital stays, altered immune
function, and impaired skin integrity and wound healing. Malnutrition has
been found to be a significant factor influencing pressure injury (PI) risk and
wound healing. While PI prevention requires multidimensional complex care
using a variety of evidence-based strategies, hospitalized patients benefit from
interventions that focus on improving oral nutrition to reduce PI risk and
enhance wound healing. Unfortunately, malnutrition is often under-
recognized and inadequately managed in hospitalized patients and this can Sandra W. Citty, PhD, ARNP-BC, CNE
lead to higher rates of complications such as PI. Submitted for publication January 24, 2019.
Recent Advances: Recent studies suggest that nutritional care has a major im- Accepted in revised form May 14, 2019.
pact in PI prevention and management. Strategies, including early identification *Correspondence: University of Florida
College of Nursing, Gainesville, FL 32610-0197,
and management of malnutrition and provision of specially-formulated oral nu- (e-mail: swolfe@ufl.edu).
tritional interventions to at-risk patients, optimization of electronic health record
systems to allow for enhanced administration, monitoring, and evaluation of
nutritional therapies, and implementation of protocol-based computerized deci-
sion support systems, have been reported to improve outcomes.
Critical Issues: Unfortunately, there are gaps in the implementation of nutri-
tional care in hospitals. Timely identification and management of malnutrition is
needed to advance quality care for hospitalized patients and reduce malnutrition
and associated PI.
Future Directions: Further research on effective, evidence-based strategies for
implementation of all stages of the nutrition care process is needed to reduce
pressure injuries and malnutrition in hospitalized patients.

Keywords: malnutrition, pressure injury, nutrition, hospitalized patients, oral

nutritional supplements

SCOPE AND SIGNIFICANCE ized patients and has been linked to

Pressure injuries in hospitalized
patients are common.1 A recent esti-
mated worldwide prevalence rate of
pressure injury (PI) in acute care
settings was between 6% and 18.5%.1
Unfortunately, malnutrition has also
been found to be a significant problem
affecting upwards of 50% of hospital-
PI risk.2,3 Early detection of malnu-
trition using validated screening and
assessment tools4 and management of
malnutrition by maximizing daily oral
nutrition with oral nutritional supple-
ment (ONS) have been shown to re-
duce development of PIs and improve
healing of existing pressure injuries.5–7

ADVANCES IN WOUND CARE, VOLUME 8, NUMBER 7

Copyright ª 2019 by Mary Ann Liebert, Inc. DOI: 10.1089/wound.2018.0925
j 309
310 CITTY ET AL.
The purpose of this review is to describe the link
between malnutrition and PIs and review current
evidence-based strategies that have the potential
to improve oral nutritional care for vulnerable
hospitalized patients.
TRANSLATIONAL RELEVANCE
Adopting evidence-based practices for PI pre-
vention is essential to move the needle on PI risk
for vulnerable hospitalized patients.4 That being
said, if there are barriers to successful adoption of
evidence-based practices for hospitalized patients,
quality of care will suffer and intended patient out-
comes will not be achieved, leading to higher health
care costs, morbidity, and mortality.8 Knowledge of
strategies to improve oral nutritional care for pa-
tients with or at-risk for PI has the potential to im-
prove care and make a positive difference for patients
and health care organizations.
CLINICAL RELEVANCE
Malnutrition has been found to be negatively
associated with poor patient outcomes especially
impaired wound healing and impaired skin integ-
rity.2,3,9,10 Recent studies have reported valuable
strategies that have been shown to improve nutri-
tion for the prevention of PI in hospitalized pa-
tients.5–7,11–19 Knowledge of these strategies, as
well as identification of potential barriers in im-
plementation, will empower clinicians to optimize
their resources and provide the best care for hos-
pitalized patients.20
BACKGROUND/OVERVIEW
Malnutrition and PI in hospitalized patients
Malnutrition in hospitalized patients is a com-
plex process related to factors such as reduced
availability and intake of nutrients, underlying
comorbidities, inflammation, and metabolic alter-
ations related to disease states and has been found
to impair wound healing.4,21 Malnutrition can de-
velop in hospitalized patients due to a variety of
factors, including anorexia, prescribed withholding
of oral feedings, inadequate attempts at oral feed-
ing, or prolonged support on a ventilator.4 Not
surprisingly, malnutrition has been identified as a
significant factor in PI development.3
PIs can present as intact skin or an open wound
and may be painful.3 Common locations of PIs are
back/sacral/coccyx areas (47%), buttock (17%), and
the heel(s) (14%).3 PIs in hospitalized individuals
can occur both before and during hospitalization. A
hospital-acquired PI (HAPI) can be the result of
several factors, some of which may be unavoidable
(age, gender, and end of life organ failure) or may
be potentially modifiable (pressure or shearing
forces, immobility, nutritional status, anemia, tis-
sue perfusion, and diabetes control). In the United
States, HAPI incidence was 0.57 per 1,000 patient
days, 3.7 cases per 1,000 patients, and 2.2 per 1,000
episodes during the period 2013–2015.22 HAPIs
have a mortality rate of 11.6%, are costly to treat,
and result in Medicare reimbursement penalties.22
See Table 1 for Factors associated with PI.
Strategies to optimize PI prevention include:
risk assessment, skin care, nutrition, positioning
and mobilization, monitoring, and leadership sup-
port.23 While there are many facets of comprehen-
sive PI prevention and care, optimizing nutrition
care has a direct link to PI prevention and man-
agement.24 Unfortunately, malnutrition in hospi-
tals is often underdiagnosed and managed. This
article is a limited review of current literature on
nutritional care strategies to reduce PIs.
DISCUSSION
Preventing pressure injuries:
optimizing nutrition care in hospitals
The Academy of Nutrition and Dietetics (AND)
established the nutrition care process (NCP), a four-
step process of assessment, nutrition diagnosis,
nutrition interventions, and monitoring/evalua-
tion.4 These steps are important to care for patients
at-risk for or with PI, as if any of these are missing
or inadequately executed, expected clinical results
will not be observed. Effective implementation of the
NCP coupled with multidisciplinary team collabora-
tion, electronic health record (EHR) solutions, and
sufficient oral nutrition support have been reported
to improve nutrition and decrease risks associated
with malnutrition in hospitalized patients.4,25,26
Unfortunately, barriers such as inadequate
knowledge by health care providers and dysfunc-
tional health system processes relating to nutrition
care and PI prevention have been identified in the
literature which can adversely impact their ability
to identify and care for at-risk patients.8,24–31 See
Table 2 for Barriers and Strategies for Optimal
Nutrition Care to Reduce Pressure Injuries.
Some solutions have been identified in the lit-
erature, including education programs and multi-
disciplinary focused care teams.28 Education on
nutrition and PI risk for hospital staff on the im-
portance of nutrition care has been reported to
positively influence outcomes.28 In fact, in a recent
study of nurses, knowledge and attitude were in-
dependently associated with the practice of sharing
patients’ nutrition information with colleagues.30
 OPTIMIZING NUTRITION PRESSURE INJURY PREVENTION 311

Table 1. Factors associated with pressure injuries

Factor Strategy for Improvement

Nutrition Use of NCP, early identification/intervention, continued monitoring and evaluation, and reassessment of hospitalized patients.
Malnutrition or poor Consider hospitalized individuals to be at risk for malnutrition from their illness or being NPO for diagnostic testing. Also consider obese
nutritional clients who do not appear visibly malnourished.
status3,6,7,23 Use a valid and reliable screening tool to determine risk of malnutrition, such as the Mini Nutritional Assessment.
Refer all individuals at risk for PI from malnutrition to a registered dietitian.
Encourage all individuals at risk for PI to consume adequate fluids and a balanced diet. Assess weight changes over time.
Assist the individual at mealtimes to increase oral intake.
Assess the adequacy of oral, enteral, and parenteral intake.
Provide nutritional supplements between meals and with oral medications, unless contraindicated.
Use EMAR for nutritional therapies such as ONS, tube feedings, and parenteral nutrition.25
Use CDSS to improve timely, evidence-based care for PIs.38
Administer high calorie, high protein formula enriched with Arginine, zinc, and antioxidants as they have been found to reduce PI occurrence
and PI size and improve healing.6,7
Impaired perfusion, Inspect the skin at least daily for signs of PI, especially nonblanchable erythema.
activity and mobility, Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, and elbows, and beneath medical devices.
friction, and shear3,23 When inspecting darkly pigmented skin, look for changes in skin tone, skin temperature, and tissue consistency compared to adjacent skin.
Moistening the skin assists in identifying changes in color.
Turn and reposition all individuals at risk for PI, unless contraindicated due to medical condition or medical treatments.
Choose a frequency for turning based on the support surface in use, the tolerance of skin for pressure, and the individual’s preferences.
Consider lengthening the turning schedule during the night to allow for uninterrupted sleep.
Turn the individual into a 30 side lying position and use your hand to determine if the sacrum is off the bed.
Avoid positioning the individual on body areas with PI.
Ensure that the heels are free from the bed.
Consider the level of immobility, exposure to shear, skin moisture, perfusion, body size, and weight of the individual when choosing a
support surface.
Continue to reposition an individual when placed on any support surface.
Reposition weak or immobile individuals in chairs hourly.
Use heel off-loading devices or polyurethane foam dressings on individuals at high risk for heel ulcers.
Place thin foam or breathable dressings under medical devices and assess often.
Use a structured risk assessment, such as the Braden Scale, to identify individuals at risk for PI as soon as possible (but within 8 h after
admission).
Refine the assessment by including these additional risk factors: Fragile skin, existing PI of any stage, including those ulcers that have
healed or are closed, Impairments in blood flow to the extremities from vascular disease, diabetes or tobacco use, Pain in areas of the
body exposed to pressure.
Repeat the risk assessment at regular intervals and with any change in condition.
Assess acute care patients every shift.
Develop a plan of care based on areas of risk.
Support surfaces should be assessed frequently and adjusted accordingly.
Use a pressure redistributing chair cushion for individuals sitting in chairs or wheelchairs.
Too much pain medication may sedate patients to the point where they don’t change position as often as they should.23
Moisture, incontinence, Cleanse the skin promptly after episodes of incontinence, fever, or evidence of excess moisture. Use skin cleansers that are pH balanced for
fever, sweating3,23 the skin.
Use skin moisturizers daily on dry skin.
Use a breathable incontinence pad when using microclimate management surfaces.23
Sensory perception pain, Patients should be assessed for their ability to move while still maintaining an acceptable level of comfort.
age, altered mental Assess individual risk factors in patients–age, previous/current PI, gender, mobility status, pressure, incontinence, altered mental status.
status, gender3,23 Interdisciplinary team meetings should include clinical team and hospital administrators to evaluate length of stay, readmission rate,
mortality data, and cost analysis.4,27
Education23,27,28,30 Teach the individual and family about risk for PI. Engage individual and family in risk reduction interventions.28
Mandatory staff education on prevention and management techniques.8,27,28,30
Length of hospital Reassess nutritional screening for hospitalized patients who have length of stay greater than expected. Evidence is unclear on the precise
stay3,9 recommendation, but evidence suggests that rescreening may be warranted for patients with length of hospital stay greater than
3–5 days.3,4,8,9,32

CDSS, computerized decision support system; EMAR, electronic medication administration record; NCP, nutrition care process; NPO, nothing per mouth or
‘‘Nil Per Os’’; ONS, oral nutritional supplement; PI, pressure injury.

To facilitate education for health care providers,
health systems should sponsor robust continuing
education offerings for staff regarding evidence for
use of standardized clinical protocols and path-
ways, nutritional screening and assessment, PI
risk, and PI prevention and treatment methods,
including early nutritional intervention for at-risk
patients.4 Regular communication and collabora-
tion among the multidisciplinary clinical team,
including the Registered Dietitian, pharmacist,
 Table 2. Barriers and strategies for optimal nutrition care to reduce pressure injuries
Barrier
Nothing by mouth and feeding
status and/or unable to tolerate
oral intake4,8
Impaired swallowing function4,8
Patient preference and/or anorexia
due to medications/disease
state4,8
Financial limitations, cost, lack
of health insurance26
Knowledge deficit and/or low
health literacy4,8,20
Loneliness during mealtime,
bereavement, depression,
social isolation
of patients4,8,20
Inadequate lighting during
mealtimes4,8,20
Mealtime interruptions4,8,20
Lack of assistance with eating4,8,20
Nutrition preferences4,8,20
Delays or inconsistent screening,
assessment, monitoring
of nutrition4,8,20,25
312 j
Strategy
Reassess and evaluate current feeding status daily.
Institute oral feeding as soon as possible to maintain adequate nutrition.
Assess need for alternative nutrition therapies, including tube feeding or parenteral nutrition.
Assess patient swallowing function and consult with multidisciplinary nutrition team, including speech therapist, to assess patient
and develop comprehensive plan to address malnutrition and PI risk.
The swallowing specialist identifies foods and beverages that the patient can safely swallow.
Offer those foods or food with the consistency that is safe for the patient to consume.
Provide patient counseling.
Assess patient preferences, choices, likes/dislikes, and reasons for lack of appetite or undernutrition.
Provide patients alternative mealtimes as they prefer or alternative food offerings to be kept on the unit for patients admitted at
off-meal times.
Discuss with patient financial options, limitation, and barriers.
Assess and plan care using a multidisciplinary approach, including consultation with social worker.
Identify resources or create protocols for reduced cost nutritional supplementation or availability of coupons for products from
pharmaceutical companies or community agencies to provide patients at hospital discharge.
Assess literacy status and education needs.
Provide patient education on current risk for malnutrition or nutrition status.
Provide patient education potential consequences of malnutrition.
Provide patient education on ways to improve his/her nutrition status.
Provide patient external coaching to enhance nutrition intake.
Provide patient education on ONS benefits.
Assess patient and consult with multidisciplinary nutrition team, including psychiatrist, psychologist, or mental health professional.
Involve family members in encouraging food and fluid intake.
Offer assistance to patient when eating and drinking.
Provide patient a dietary helper or assistant that stays with patient during meal times.
Ask family or significant others to visit during mealtimes and encourage them to eat with the patient.
Consult chaplain or social worker for additional resources.
Assess hospital room lighting and assess potential areas for improvement.
Ask patients/families their preferences and opinions of current hospital environment for eating.
Establish regular consistent mealtimes.
Limit noncritical interruptions during mealtimes.
Schedule routine care before or after mealtimes.
Provide encouragement and time to eat meals and encouragement and time to consume nutritional supplements.
Assess staffing patterns.
Query patients and family members regarding their perspective of adequacy of mealtime resources.
Provide support, assistance, or companionship at mealtimes.
Ask family to assist loved ones during mealtimes.
Use of dietary aids or mealtime assistants at mealtimes.
Assess patients at risk for undernutrition and who may need assistance or reinforcement when eating.
Assess patient’s preferences (type or form of ONS i.e., beverage, hot vs. cold, pudding, cookie, flavor, and so on)
Offer a variety of high-energy density food, low volume/small portions, palatability, appetizing appearance, and variety of flavors
and textures.
Provide energy-containing liquids between meals.
Offer fluids with flavoring to enhance palatability.
Encourage patient to drink more water especially with large draining wounds or fistulas, encourage eating foods that have high
water content (cucumbers, watermelon, and celery).
Offer patients a variety of hot and cold beverages.
Encourage patients to drink all fluids with medications and meals.
Offer small amount of fluids regularly.
Provide refillable water bottle and add cup holder to wheelchair to encourage drinking.
Provide convenient, accessible food and nutrition sources.
Stock high quality food and nutrition sources on hospital inpatient units that are easily accessible to staff, including fresh fruits and
vegetables, whole grain, and protein sources.
Assessment daily and when clinical condition changes or progress is not met.
Assess all patients using a reliable tool, including those with obesity or no obvious signs of undernutrition.
Document and evaluate assessment and make recommendations and changes to plan of care promptly.
Use of standardized daily assessment tool in the EHR for nursing, physicians, and dietitians utilizing a standardized nutrition
assessment tool.
Perform assessment within 24 h of admission to acute care facility.
Institute a nutrition plan of care for all patients who have increased metabolic needs, risk of malnutrition, or documented diagnosis
of malnutrition. Initiate step-wise approach to nutrition interventions and feeding; if not tolerating or able to take oral intake or
not tolerating tube feeding.
Automated implementation of nutrition protocols for at-risk patients to reduce delays in beginning interventions.
(continued)
 OPTIMIZING NUTRITION PRESSURE INJURY PREVENTION 313

Table 2. (Continued )

Barrier Strategy

Nutrition may be a low priority for
organization or health care
provider4,8,20,32
Fragmented ordering, administration
and documentation of nutritional
supplements, errors of omission
of nutritional orders25
Nutrition supplement process
and workflow20,23,38
Malnutrition diagnosis4,8,38,39
Provider education and
knowledge8,20,27–29
Create a culture where nutrition is valued as an essential medical intervention that reduces length of hospital stay, pressure
injuries, falls, infection, depression, health care costs, morbidity, and mortality.
Active and regular communication among interdisciplinary care teams for nutrition care.
Engagement of hospital administrators in interdisciplinary workgroups for nutrition care.
Utilize EHR effectively to standardize ordering, administration and documentation of nutrition supplements, nutritional medications,
tube feeding, and parenteral nutrition.
Utilize protocol-driven CDSS for nutrition care.
Utilize EMAR or standardized method for administration and documentation of nutrition medications such as nutritional supplement,
protein and micronutrient supplements, tube feedings, and parenteral nutrition to improve the administration and documentation
of nutritional interventions.
Perform quality and process improvement to evaluate current processes and needs for improvement.
Devise system to assess, intervene, and monitor nutrition status in a streamlined consistent manner.
Use automated CDSS solutions to enhance NCP.
Verify at least two of the six ASPEN characteristics to confirm malnutrition diagnosis: Insufficient energy intake, weight loss, loss of
muscle mass and subcutaneous fat, localized or generalized edema, and diminished functional status as measured by hand grip
strength.
Incorporate nutrition screening and assessment as part of CDSS in EHR.
Diagnosing health care providers should use ‘‘Six Key Elements for Documenting Malnutrition’’ to provide complete documentation,
including: History and clinical diagnosis, clinical signs and physical examination, anthropometric data, laboratory indicators,
dietary data, and functional outcomes.
Assess health care provider’s knowledge and opinion of nutrition as an important aspect of patient care and improving outcomes.
Mandatory education for front-line health care providers who provide direct clinical care for patients.
Education on risks of malnutrition, costs and benefits of early initiation of nutrition, and benefits of nutritional supplements.

ASPEN, American Society for Parenteral and Enteral Nutrition; EHR, electronic health record.

Registered Nurse, nurse practitioner, clinical
nurse specialist, physician, wound care specialist,
and speech therapist, have also been shown
to promote better patient outcomes for patients
with or at-risk for malnutrition or PI.4,7,27,31 These
teams should meet on a consistent basis (i.e., in-
terdisciplinary daily rounds and weekly to monthly
team strategy meetings) to tackle issues such as
implementing nutrition protocols, performing
quality improvement (QI) and assessing outcomes,
monitoring data trends, and providing staff educa-
tion related to comprehensive nutrition care.25,27,31
Optimizing nutrition screening
and assessment
Screening for nutritional deficiencies is often
completed during hospital admission by Registered
Nurses in collaboration with the health care team
using standardized, paper or electronic, nutrition
screening forms that can trigger a consult to the
Registered Dietitian if the patient is deemed to be
at high risk of malnutrition.26 All patients in the
hospital have a potential to decline in health and
should be monitored and rescreened for malnutri-
tion throughout their hospitalization (daily or as
condition warrants) using validated tools.9,32
Unfortunately, it has been reported that nutri-
tion screening and assessment are not consistently
applied within hospital systems.27 Furthermore,
patients may decline through lengthy hospital
stays, and rescreening for malnutrition is not gen-
erally a standardized practice in many hospitals.9
The Joint Commission requires that a nutritional
screening is performed when warranted by the
patient’s condition (or hospital policy) and must be
completed, when applicable for the patient’s con-
dition, within 24 h after inpatient admission.33
To assist clinicians, several nutritional screen-
ing tools have been validated for use in acute care
settings, including: the Malnutrition Screening
Tool (MST), the Malnutrition Universal Screening
Tool (MUST), the Nutrition Risk Screening (NRS)
tool, Subjective Global Assessment (SGA), Patient-
Generated SGA (PG-SGA), Mini-Nutritional As-
sessment (MNA), MNA-Short Form (MNA-SF),
and the NUTRIC (Nutrition Risk in the Critically
Ill) score.4,34–36 The Global Leadership Initiative
on Malnutrition (GLIM) Criteria is a newer as-
sessment tool that is currently being validated for
use in acute care settings.37
Screening tools can be completed by any member
of the health care team. Identifying patients with
or at-risk-for malnutrition will warrant a compre-
hensive nutrition assessment by a Registered
Dietitian. Unfortunately, the utilization and ap-
plication of these nutrition screening tools vary
across clinical situations or specifically in patients
with PI.27
314 CITTY ET AL.
Promising strategies to enhance systematic use
and communication of this clinical screening and
assessment information with complex patients are
the use of computerized decision support system
(CDSS). CDSS has been found to improve applica-
tion of complex evidence-based protocols and clin-
ical decision-making and be a positive impact on
complicated health issues, such as PI and malnu-
trition.38,39 At the current time, CDSS has not been
widely implemented in hospitals even though they
have been found to improve a variety of health care
outcomes, including PI.38,39
Optimizing nutrition diagnosis,
coding, and reimbursement
The AND and the American Society for Par-
enteral and Enteral Nutrition (ASPEN) recommend
that a standardized set of diagnostic characteristics
be used to identify and document adult malnutrition
in routine clinical practice.4 Furthermore, these
bodies identified the following six criteria to deter-
mine the patient’s nutritional status. Patients are
considered to be nutritionally compromised when
they exhibit at least two of the following six criteria:
(1) insufficient energy intake; (2) weight loss; (3) loss
of subcutaneous fat; (4) loss of muscle mass; (5) lo-
calized or generalized fluid accumulation that may
sometimes mask weight loss; and (6) diminished
functional status.4
Despite these recommendations, malnutrition
continues to be underidentified, coded, and reim-
bursed in hospitals.2,40,41 In fact, it has been re-
ported that only 3% to 5% of hospitalized population
are diagnosed with malnutrition, although it is es-
timated that 30–60% of the hospitalized population
are malnourished.2,41
To enhance coding and reimbursement of
malnutrition-related diagnosis, physicians should
include at least the six elements of documentation
of malnutrition into their standardized docu-
mentation. These include: (1) History and clinical
diagnosis (presence of inflammatory processes or
nutritional impairments); (2) Clinical signs and
physical examination (inflammation, fever, hypo-
thermia, tachycardia, tachypnea, edema, and
weight gain/loss); (3) Anthropometric data (height,
weight, BMI, weight loss history, and body com-
position metrics); (4) Laboratory indicators for
inflammation and severity of illness (elevated C-
reactive protein, low albumin, low pre-albumin,
low or high WBC count, elevated glucose, negative
nitrogen balance, and elevated metabolic rate); (5)
Dietary data (modified diet history or 24-h diet
recall); and (6) Assessment of functional outcomes
(strength/physical performance).4
If warranted, malnutrition should be included in
the patient’s coded diagnosis; a multidisciplinary
nutrition care plan and prescribed nutrition inter-
ventions should be implemented within 48 h of
identification of malnutrition.32 Appropriate coding
of malnutrition diagnosis allows for reimbursement
for care-related expenses to maintain resources for
delivery of quality care. Examples of ICD-10 Diag-
nosis codes related to malnutrition are included in
Table 3. See Table 3 For ICD-10 Diagnosis Codes for
Malnutrition Related Diagnoses.40,41
Optimizing oral nutrition care
In an optimal setting, oral nutrition is the pre-
ferred route for nutrition, and it is obtained in ad-
equate amounts to sustain and maintain the body’s
physiological demands during extended periods
of immobility, stress, inflammation, and illness.
Table 3. ICD-10 diagnosis codes for malnutrition
related diagnoses40,41
ICD-10 Criteria/Description
E40 Kwashiorkor Nutritional edema with depigmentation of skin
and hair.
E42 Marasmic Kwashiorkor.
E41 Nutritional Marasmus.
Nutritional atrophy; severe malnutrition otherwise stated,
severe energy deficiency.
E43 Unspecified severe protein-calorie malnutrition
Nutritional edema without mention of dyspigmentation of skin
and hair.
E44.0 Moderate protein-calorie malnutrition.
E44.1 Mild protein-calorie malnutrition.
E45 Retarded development following protein-calorie malnutrition.
E46 Unspecified protein-calorie malnutrition.
E46 Unspecified Protein-calorie malnutrition.
A disorder caused by a lack of proper nutrition or an inability to
absorb nutrients from food. An imbalanced nutritional status
resulted from insufficient intake of nutrients to meet normal
physiological requirement. Inadequate nutrition resulting
from poor diet, malabsorption, or abnormal nutrient
distribution. The lack of sufficient energy or protein to meet
the body’s metabolic demands, as a result of an inadequate
dietary intake of protein, intake of poor quality dietary
protein, increased demands due to disease, or increased
nutrient losses.
E64 Sequelae of protein-calorie malnutrition.
E66.01 Morbid (severe) obesity due to excess calories.
R63.6 Underweight. Use Additional code to identify body mass index
(BMI), if known (Z68.-) Type 1 Excludes abnormal weight loss
(R63.4) anorexia nervosa (F50.0-) malnutrition (E40–E46).
R63.4 Abnormal weight loss.
R64 Cachexia. Applicable To Wasting syndrome Code First
underlying condition, if known Type 1 Excludes abnormal
weight loss (R63.4) nutritional marasmus (E41).
Z68.1 Body mass index (BMI less than 19, adult).
 OPTIMIZING NUTRITION PRESSURE INJURY PREVENTION
Patients who have impaired oral tolerance or dif-
ficulty swallowing may require feeding through
enteral tube or intravenous nutrition in the form of
parenteral nutrition.4
All hospitalized patients should receive a well-
balanced diet and maintain adequate nutrition
while being hospitalized.4 Adequate energy
sources (carbohydrates and fats), protein sources
(e.g., animal or vegetable proteins), amino acids
(leucine), hydration (water, fluids, and food
within fluids), and vitamins and minerals are
important for skin integrity and enhancing wound
healing.4,20,30,40–42
Optimal nutrition, including sufficient energy,
carbohydrate, protein, amino acid, and fat and
micronutrient intake in patients, has been found to
facilitate prompt and effective skin integrity
maintenance and wound healing.3,4,24,42,43 When
designing any individualized nutrition care plan
for a patient with malnutrition and/or PI, health
care providers should provide a variety of foods to
ensure that carbohydrates, fats, and proteins, as
well as micronutrients and adequate hydration,
are sufficient to meet estimated requirements.24
Vitamins such as Vitamin A, Vitamin C, Zinc, and
Copper have all been implicated in wound healing
and immune system function.24,44
Ideally, patients at risk of or with PIs should
obtain adequate vitamins and minerals from
dietary sources such as those listed below. The
2014 International Guidelines for Prevention
and Treatment of PI recommend providing and
encouraging an individual assessed to be at risk
of a PI to take vitamin and mineral supple-
ments when dietary intake is poor or deficiencies
are confirmed or suspected.4 Furthermore, other
sources provide recommendations on supple-
mentation of Vitamins for the treatment of PIs,
although evidence is limited and more research is
needed.24,43
Vitamin C
Vitamin C in wound healing may impact collagen
formation, immunomodulation, and antioxidant
functions; however, evidence is limited and supple-
mentation is only indicated in a documented defi-
ciency.21,24,43 The recommended dietary allowance
(RDA) for Vitamin C is 90 mg/day for adult men and
75 mg/day for adult women. The tolerable upper
limit (UL) for Vitamin C is 2,000 mg (11,360 lmol)/
day.43 Vitamin C deficiency may result in impaired
immune response during the inflammatory phase
with increased capillary fragility and reduced col-
lagen tensile strength, which can impact PI risk and
healing. Doses between 250 and 1,000 mg/day of
315
Vitamin C in divided doses have been recommended
for patients who have poor dietary intake to en-
hance wound healing for PI.4,24 Up to 1,000 to
2,000 mg/day for Stage 3 or 4 PI and for highly
stressed, malnourished, or seriously injured pa-
tients has also been recommended.24 However,
giving high dosages of Vitamin C may be contra-
indicated in individuals with a history of calcium
oxalate kidney stone formation.43 Dietary sources
of Vitamin C include: oranges, red pepper, kale,
Brussel sprouts, broccoli, strawberries, grapefruit,
and guava.21,24,43
Vitamin A
Vitamin A may be helpful in wound healing
especially in patients who have a documented de-
ficiency or who have inadequate intake of foods
rich in Vitamin A.24,44,45 The RDA for Vitamin A for
healthy adult males is 900 lg retinol activity
equivalents (RAE) and for females is 700 lg RAE.45
The tolerable UL for preformed Vitamin A is
3,000 lg RAE/day.45 Vitamin A dosing for PI man-
agement (all stages) has been recommended to be
3,000–15,000 lg RAE per day orally for injured or
severely malnourished persons.24 Molnar rec-
ommends oral Vitamin A at 6,000–7,500 lg RAE
per day to enhance wound healing in patients
receiving corticosteroids.44 Dietary sources of
Vitamin A include: Liver and fish oils, green leafy
vegetables, orange and yellow vegetables, and
tomatoes.24,45
Zinc
Zinc supplementation has been found to be helpful
in wound healing for patients who have zinc defi-
ciency due to poor dietary intake or increased losses
of zinc.6,7,24 The RDA of Zinc for healthy males is
11 mg/day and for females is 8 mg/day.45 The toler-
able UL for Zinc is 40 mg/day.45 Zinc toxicity is as-
sociated with impaired neutrophil and lymphocyte
function and calcium and copper binding. Excess
zinc supplementation is associated with gastro-
intestinal track irritation, nausea, vomiting, and
diarrhea. Chronic intakes of zinc can result in a
copper deficiency because they compete for the
same receptor sites.45 Dietary sources of zinc in-
clude: Oysters, beef, crab, lobsters, chickpeas,
nuts, cheese, yogurt, pork, fish, and fortified
breakfast cereals.45
Copper
Copper is an essential nutrient required for col-
lagen cross-linking and it may play a role in angio-
genesis and promote wound healing, although exact
mechanisms are unclear. Copper is destructive to
bacterial strains, and it may be helpful in immune
316 CITTY ET AL.
function, evidence is limited. Recommended daily
intake of Copper for adult males and females is
900 lg/day.45 The tolerable UL for adults is 3,000
RAE/day (10,000 IU/day).45 Critical adverse effect of
copper toxicity is liver toxicity and there is reduced
Copper absorption when Zinc is supplemented.45
Dietary sources of Copper include: Oysters, dark
chocolate, liver, and sesame seeds.24,45
Optimizing Oral Nutritional Supplements
An ONS is a product designed to meet macro and
micronutrient needs of individuals who cannot
meet their nutritional requirements through their
current dietary intake.46 FDA defines ‘‘dietary
supplements’’ in global terms to include both ONSs
and vitamin mineral supplements. In health care
settings, there is a distinction between products
that contain energy and replace or fortify food
(ONSs) versus micronutrient (vitamin and mineral
supplements) or herbal supplements.46
Nutritional (also referred to as dietary) supple-
ments are supplied as tablets, capsules, powders,
energy bars, and liquids and are widely available in
the United States and on the Internet.46 The Na-
tional Pressure Ulcer Advisory Panel (NPUAP),
European Pressure Ulcer Advisory Panel (EPUAP),
and the Pan Pacific PI Alliance (PPPIA) Nutrition
Guidelines for 2014 recommend offering fortified
foods and/or high-energy, high protein, ONS be-
tween meals if nutritional requirements cannot be
achieved by dietary intake alone.4 The strength
of evidence is rated as ‘‘B’’ (the recommendation
is supported by direct scientific evidence from
properly designed and implemented clinical se-
ries on PI in humans or humans at risk for PI,
providing statistical results that consistently
support the recommendation (levels 2, 3, 4, 5
studies). The strength of this recommendation is
rated as a ‘‘strong positive recommendation: def-
initely do it.’’4
Studies show that consumption of specialized,
nutrient-enriched ONS improves outcomes for
malnourished hospitalized patients who are ei-
ther at risk for PI or who have PI, although the
studies are of limited quality and size.5–7,11–19 Re-
cently, Cereda et al. published a systematic review
of randomized control trials from January 1997 to
October 2015 and found that compared to control
interventions, ONS enriched with arginine, zinc,
and antioxidants resulted in significant reduction
in wound area (-15.7% [95% confidence interval,
CI: -29.9 to -1.5]; p = 0.030; I2 = 58.6%) and a higher
proportion of subjects had a 40% or greater reduc-
tion in PI size (odds ratio = 1.72 [95% CI: 1.04 to
2.84]; p = 0.033; I2 = 0.0%) at 8 weeks. This meta-
analysis found that the use of ONS enriched with
arginine, zinc, and antioxidants as oral supple-
ments and tube feeds for at least 8 weeks was as-
sociated with improved PI healing compared with
the use of standard nutritional ONS.7
Furthermore, studies show that positive out-
comes (reduced costs, mortality, length of hospi-
tal stay, and complications such as PI) have been
found when malnutrition was identified promptly
(within 24 h) and nutrition intervention (using
ONS) was initiated early and in a standardized
manner.4,10,25,47 For example, the Cleveland
Clinic in Akron, Ohio conducted a QI project to
assess the impact of prompt nutrition care on
health care outcomes.47 This retrospective study
reviewed 20,000 hospitalized records and found
decreased HAPI prevalence by 50% (from 40 PIs
to 20 PIs) from quarter to quarter after im-
plementing automated screening and interven-
tion protocol (ONS) for at-risk patients.47
A brief review of literature of the current un-
derstanding of the use of ONS and PI is presented
in Table 4. Literature from PubMed and CINAHL
database from 2014 to 2019 was reviewed using
keywords: nutrition, PI, malnutrition, and ONS.
Considering the evidence, there may be significant
benefits that patients and hospital systems may
see when nutrition care is optimized using spe-
cialized formulations of ONS.
Optimizing nutrition monitoring
Nutrition monitoring (and evaluation) are es-
sential steps that are often incomplete or missing
within hospital EHRs and this leads to poor out-
comes such as PI and malnutrition, among oth-
ers.4,25,47 Effective monitoring and evaluation
require the complete evaluation of food and nutri-
ent intake, food and nutrient administration,
complimentary/alternative medication use, knowl-
edge/belief, food and supplies available, physical
activity, and nutrition quality of life.4
According to the Agency for Health Care Re-
search and Quality in 2008, supplements such as
herbals, vitamins, and nutritional supplements
should be part of the patient’s medication history
and be reconciled with other medications listed on
the medication administration record (MAR).48
Inadequate administration and documentation
of nutrition therapies, including ONS, has been
found to be a significant problem in hospitals
and has been identified as a barrier in the im-
plementation and evaluation of nutritional care
and prevention of pressure injuries.25,27,49,50 In
fact, in many hospitals, nutrition therapies are of-
ten documented as volume-only in the intake
 Table 4. Disease-specific oral nutritional supplements and pressure injury outcomes (2014–2019)
Study Type, Aim, Sample Size,
Reference Study Setting, Study Duration
6
Cereda, et al. Randomized controlled trial.
Two-group (parallel assignment),
randomized, controlled, blinded clinical
trial (February 2010 to November 2012).
n = 200 malnourished patients
Location: seven long-term and home care
sites in Italy
Study Duration: 8 weeks
Pouyssegur, Randomized controlled trial
et al.18 Aim: To evaluate the impact of a solid
nutritional supplement on the weight gain
of institutionalized older adults >70 years
with protein-energy malnutrition. The
innovation of these high-protein and high-
energy cookies was the texture adapted to
edentulous patients
n = 175 elderly participants
Location: seven nursing homes
Study Duration: 6 weeks
Wong, et al.17 Randomized, controlled clinical trial
Aim: To compare pressure ulcer healing rates
in patients supplemented with a
specialized amino acid mixture containing
HMB, arginine, and glutamine and
standard ONSs versus patients
supplemented with ONSs and a placebo
mixture.
n = 23 patients (inpatient acute care hospital)
with stage II,III, or IV pressure injuries
Location: Acute inpatient hospital Singapore
Study Duration: 2 weeks
j
317
Active Intervention
n = 101
Standard diet plus two specific ONS per
day (27.5 kcal/kg/day; 1.5 g/kg/day)
n = 88
Standard diet plus eight high-protein,
high-energy cookies per day (11.5 g
protein; 244 kcal) for 6 weeks. Each
cookie weighed 6.5 g and contained
1.44 g of protein, 30.5 kcal, and 22%
of weight in proteins. Total energy
content in proteins was 19% with an
animal/vegetable protein ratio of 3.5
and a glycemic index of 46.1. Eight
cookies were distributed in the
breakfast and/or in the snack (total
52 g of cookies: 11.5 g of protein and
244 kcal as daily supplementation).
n = 11
Randomized to receive either standard
diet plus a HMB, arginine, and
glutamine mixture twice daily
alongside ONSs
Control Intervention
n = 99
Standard diet plus two
isocaloric, isonitrogenous
ONS/day (27.0 k/cal/kg/
day; 1.5 g/kg/day)
n = 87
Standard diet
n = 12
Standard nutritional care
alongside ONSs/placebo
mixture
Outcome Measures
Pressure ulcer healing using
wound perimeter tracing
using VISTRAKTM system
Five measurements over 6 week
period
Percentage of weight gain in kg
Appetite (numerical scale 1–10),
frequency of diarrhea, and
pressure ulcers
Pressure ulcers were measured
weekly for area, depth, and
Pressure Ulcer Scale for
Healing (PUSH) scores. The
proportion of viable tissue
was determined based on
area of wound tracing.
Weekly measurements of C-
reactive protein and pre-
albumin levels.
Results/Limitations
Supplementation with the enriched formula
(n = 101) resulted in a greater reduction in
pressure ulcer area (mean reduction, 60.9%
[95% CI: 54.3 to 67.5]) than with the control
formula (n = 99) (45.2% [95% CI: 38.4 to 52.0])
(adjusted mean difference, 18.7% [95% CI: 5.7
to 31.8]; p = 0.017). A more frequent reduction
in area of 40% or greater at 8 weeks was also
seen (OR: 1.98, [CI: 1.12 to 3.48]; p = 0.018).
No difference was found in terms of the other
secondary end points.
Limitations: small study, one country, lost *25%
to follow-up
Significant increase in weight in the intervention
group (n = 88) compared to that of the control
group (n = 87), which lacked cookie
supplementation (+1.6 vs. -0.7%, p = 0.038).
Weight gain persisted 1 month (+3.0 vs.
-0.2%, p = 0.025) and 3 months after the end
of cookie consumption (+3.9 vs. -0.9%,
p = 0.003). Subgroup analysis confirmed the
positive impact of cookie supplementation
alone on weight increase ( p = 0.024), appetite
increase ( p = 0.009), and pressure ulcer
reduction ( p = 0.031).
Limitations: small sample size, variety of diets
between facilities and participants, may not
have controlled for other supplements taken.
The proportion of viable tissues increased within
2 weeks on HMB, arginine, and glutamine
supplementation ( p = 0.02). PUSH scores
showed significant improvement within 1
week of supplementation for the experimental
group ( p = 0.013).
No difference between anthropometrical
measurements, biochemical parameters, and
nutritional intake pre- and poststudy. Wound
area did not decrease significantly in the short
term for both groups.
Limitations: small sample, one location, short
duration, variety of pressure ulcer stages and
locations.
(continued)
318
j
Table 4. (Continued )
Study Type, Aim, Sample Size,
Reference Study Setting, Study Duration
Neyens, et al.11 Descriptive literature review
To evaluate the effects of arginine-enriched
oral nutritional supplementation in
pressure ulcers.
Reviewed seven randomized controlled trails
and four controlled trails, published
between January 2001 and October 2015
and conducted in different settings:
hospital, long-term care, and home care.
The duration of follow-up of the studies
varied from 2 weeks to complete healing
and the sample size varied from 16 to 245
patients aged from 37 to 92 years and
with pressure ulcer stages II, III, or IV.
Neyens, et al.14 Quasi-experimental study.
Aim: To explore the effects of a specific
arginine-enriched ONS on the healing of
chronic wounds in nonmalnourished
patients.
n = 27 patients with arterial leg ulcers,
venous leg ulcers, diabetic foot ulcers,
and pressure ulcers
Location: three clinical centers in the
Netherlands
Study Duration: 12 weeks
Cereda, et al.7 Systematic review of publications between
January 1997 and October 2015
Reviewed randomized controlled trails from
January 1997 to October 2015 and found
three studies that met the inclusion
(formula with arginine, zinc, and
antioxidants given for at least 4 weeks
duration in patients with pressure ulcer)
CI, confidence interval; HMB, beta-hydroxy-beta-methylbutyrate; N/A, not applicable; OR, odds ratio.
Active Intervention
The wound-specific ONS servings varied
from one to three times per day, and
contained 3–9 g of arginine per ONS.
Participants consumed a specific ready
to drink arginine-enriched ONS daily,
in addition to their regular diet and
standard wound care, for a maximum
of 12 weeks
N/A
Control Intervention Outcome Measures
N/A Pressure ulcer healing, time
needed for complete wound
closure, reduction in wound
surface area, nursing time,
and the number of dressings
used.
None Pressure ulcer healing, wound
surface area, compliance, and
rating with specific nutritional
supplement
N/A Assessed effects of high calorie
disease specific nutrition
support given at least 4
weeks duration compared to
control in patients with
pressure ulcers. Pressure
ulcer healing, pressure ulcer
size
Results/Limitations
10/11 studies showed a beneficial effect of the
arginine-enriched oral nutritional
supplementation on the healing of pressure
ulcers.
Limitations: Studies available were small,
different populations, variety of interventions,
dosages, duration, and follow-up.
Seventeen females and 12 males with a mean
age of 73.7 years were included. Within 2 to
12 weeks, complete healing occurred in 8/12
ulcers, 13 ulcers had decreased wound
surface area ranging from 25% to 88%
reduction. 3/12 ulcers were unchanged.
Overall, the daily ONSs, on average two
servings per day ( = 400 mL), were almost fully
consumed (99.5%), and the patients’ rating of
the ONS was good.
Limitations: small study, no control group,
subjects regular diet not controlled, multiple
types of wounds evaluated.
Formulas enriched with arginine, zinc, and
antioxidants resulted in significant reduction
in ulcer area (-15.7% [95% CI: -29.9 to -1.5];
p = 0.030; I2 = 58.6%) and a higher proportion
of subjects having a 40% or greater reduction
in PU size (OR = 1.72 [95% CI: 1.04 to 2.84];
p = 0.033; I2 = 0.0%) at 8 weeks.
Limitations: Small number of studies evaluated
(3), studies evaluated had small sample sizes
and short duration, variety of dosages,
formulations, and durations of therapy for
each study
 OPTIMIZING NUTRITION PRESSURE INJURY PREVENTION 319

Figure 1. Scheduled MAR—Nutrition Supplement Order. MAR, medication administration record. AMB, ambulatory; PRN, as needed. Color images are
available online.

flowsheet of the medical record, and often hospitals
do not have a process for scheduled administration
and documentation. Furthermore, in many acute
care institutions, if the ONS is not ingested or is
refused, it is not documented.25,49,50
Solutions that allow for standardized ordering,
administration, and documentation of nutritional
therapies within the medication administration
process have been identified recently in the liter-
ature.25,49 For example, Citty, et al. reported on a
hospital systems’ efforts to develop an electronic
nutrition medication record (ENAR) within an
existing EHR to improve ordering, administra-
tion, documentation, and evaluation of ONS
within the medication record. The authors found
that this improved the process and workflow of the
system, as well as improved the documentation
of nutritional medications. Although more stud-
ies are needed, this study showed positive gains
and may be a potential solution for hospital sys-
tems. Because the strategy of including nutri-
tional therapies as part of electronic MAR (EMAR)
is not widely utilized in many U.S. hospitals,
examples of ENAR administration and docu-
mentation screens in the EHR are provided in
Figs. 1–3.25
SUMMARY
PIs and malnutrition are common in hospital-
ized patients.2,3 Although PIs often occur due to
multifactorial causations, malnutrition was the
most significant factor in PI incidence in a recent
evaluation of over seven million inpatient admis-
sions.3 To facilitate prompt assessment, diagnosis,
intervention, and monitoring of nutrition, CDSS
infused with evidence-based protocols should be
implemented in hospitals.32,38,39
When patients are identified as at-risk for or
having malnutrition or PI, prompt referral to a
Registered Dietitian is warranted. In addition,
health care providers should assure provision of

Figure 2. EMAR—Oral Nutritional Supplement Administration Screen. EMAR, electronic MAR. Color images are available online.
320
Figure 3. EMAR—Embedded Intake Flowsheet Rows Linking Administration and Intake Volume Automatically. Color images are available online.
mealtime assistance to increase oral intake. Col-
lectively, evidence suggests that giving patients
high energy, high protein ONS enriched with
arginine, zinc, and antioxidants is helpful in
reducing PI occurrence, PI size, and improving
healing.6,7,11–17
Studies show that effective strategies that op-
timize oral nutritional care are those that are
evidence based, timely, standardized, scheduled,
and consistent with maximization of the EHR
and CDSSs.31,32,38,39,47
FUTURE DIRECTIONS
Further discovery of evidence-based practices
for nutrition optimization (therapeutic approaches
as well as enhanced systems) to reduce PIs is
needed to improve care of the vulnerable hospita-
lized patient. More quality research studies on
best practices (type, amount, formulation, and
frequency of interventions) for prevention of PI
using ONS is needed.
ACKNOWLEDGMENT AND
FUNDING SOURCES
The authors acknowledge the editorial support
of Ms. Deborah MacDonald, Editor, Office for Re-
search Support at the University of Florida College
of Nursing.
CITTY ET AL.
AUTHOR DISCLOSURE AND GHOSTWRITING
S.W.C., PhD, ARNP-BC, CNE: No competing
financial interests exist. The content of this article
was expressly written by the authors listed. No
ghostwriters were used to write this article.
L.J.C., PhD, ARNP, FNP-BC, CWS: No competing
financial interests exist. The content of this article
was expressly written by the authors listed. No
ghostwriters were used to write this article. Z.W.,
BSN, RN: No competing financial interests exist.
The content of this article was expressly written
by the authors listed. No ghostwriters were used
to write this article. J.S., PhD, ACNP-BC, FAAN:
No competing financial interests exist. The con-
tent of this article was expressly written by the
authors listed. No ghostwriters were used to write
this article.
ABOUT THE AUTHORS
Sandra W. Citty, PhD, ARNP-BC, CNE, is
a clinical associate professor in the University
of Florida College of Nursing in Gainesville
Florida. Her scholarship area is in quality/pro-
cess improvement and system redesign, specifi-
cally focusing on nutrition and inpatient nursing
practice and improving patient outcomes. Linda
J. Cowan, PhD, ARNP, FNP-BC, CWS, is the
Associate Chief Nursing Service/Research at the
Tampa VA Center of Innovation for Disability
 OPTIMIZING NUTRITION PRESSURE INJURY PREVENTION 321

and Rehabilitation Research (CINDRR)

TAKE-HOME MESSAGES
in Tampa Florida. She has an active
research program on chronic wounds  It is estimated that up to 50% of hospitalized patients are malnourished,
and pressure injuries. Zandra Wingfield, and malnutrition is significantly associated with PI risk.
BSN, RN, is a 2015 graduate of the  HAPIs, PIs, and malnutrition increase health care costs, length of hospital
University of Florida College of Nur- stays, and hospital readmission rates.
sing. She completed her undergraduate  Early and frequent screening and assessment of nutrition, skin integrity,
honors research in the area of nutrition and PI risk (within 24-h of hospital admission and rescreening daily or
quality improvement in hospitalized more frequently if condition or intervention changes or patient deterio-
patients. Joyce Stechmiller, PhD, rates) while patients are hospitalized are recommended.
ACNP-BC, FAAN, is Associate Pro-  Evidence suggests that giving patients high energy, high protein ONS
fessor at the University of Florida Col- enriched with micronutrients and antioxidants within 24–48 h after iden-
lege of Nursing in Gainesville, Florida. tification of risk is helpful in reducing length of hospital stay, readmission
Dr. Stechmiller’s research interests fo- rate, health care costs, PI occurrence, and PI size and improves healing.
cus on biobehavioral aspects of chronic  Utilize EMAR for documenting nutritional therapies to enhance stan-
wound healing including symptoms, dardized ordering, administration, documentation, evaluation, and med-
immune function, nutritional status ication reconciliation and safety.
and interventions for wound healing
 Multidisciplinary team-based care, performance and quality improve-
in adults and older adults. She held
ment/monitoring, and staff knowledge have been found to impact nu-
membership on the Board of Directors
trition outcomes and PI prevention for hospitalized patients.
of the National Pressure Ulcer Advisory
Panel and was previously a Board  Automated CDSS solutions to standardize timely, protocol-driven prac-
member of the Wound Healing Society. tices have been found to reduce PI.
She is an editor of Advances in Wound  Further research on best practices (type, amount, formulation, and fre-
Care. quency of interventions) for prevention of PI using ONS is needed.

REFERENCES
1. Tubaishat A, Papanikolaou P, Anthony D, Habi-
ballah L. Pressure ulcers prevalence in the acute
care setting: a systematic review, 2000–2015.
Clin Nurs Res 2018;27:643–659.
2. Konturek PC, Herrmann HJ, Schink K, Neurath MF,
Zopf Y. Malnutrition in hospitals: it was, is now,
and must not remain a problem! Med Sci Monit
2015;21:2969–2975.
3. Bauer K, Rock K, Nazzal M, Jones O, Qu W.
Pressure ulcers in the United States’ inpatient
population from 2008 to 2012: results of a ret-
rospective nationwide study. Ostomy Wound
Manage 2016;62:30–38.
4. Posthauer ME, Banks M, Dorner B, Schols JM. The
role of nutrition for pressure ulcer management:
National Pressure Ulcer Advisory Panel, European
Pressure Ulcer Advisory Panel, and Pan Pacific
Pressure Injury Alliance white paper. Adv Skin
Wound Care 2015;28:175–188; quiz 189–190.
5. Langer G, Fink A. Nutritional interventions for
preventing and treating pressure ulcers. Cochrane
Database Syst Rev 2014;6:CD003216.
6. Cereda E, Klersy C, Serioli M, Crespi A, D’Andrea F. A
nutritional formula enriched with arginine, zinc, and
antioxidants for the healing of pressure ulcers: a
randomized trial. Ann Intern Med 2015;162:167–174.
7. Cereda E, Neyens JC, Caccialanza R, Rondanelli
M, Schols JM. Efficacy of a disease-specific nu-
tritional support for pressure ulcer healing: a
systematic review and meta-analysis. J Nutr
Health Aging 2017;21:655–661.
8. Kozeniecki M, Pitts H, Patel JJ. Barriers and so-
lutions to delivery of intensive care unit nutrition
therapy. Nutr Clin Pract 2018;33:8–15.
9. Allard JP, Keller H, Jeejeebhoy KN, et al. Decline
in nutritional status is associated with prolonged
length of stay in hospitalized patients admitted
for 7 days or more: a prospective cohort study.
Clin Nutr 2016;35:144–152.
10. Elia M, Normand C, Norman K, Laviano A. A
systematic review of the cost and cost effec-
tiveness of using standard oral nutritional sup-
plements in the hospital setting. Clin Nutr 2016;
35:370–380.
11. Neyens JC, Cereda E, Meijer EP, Lindholm C,
Schols JMGA. Arginine-enriched oral nutritional
supplementation in the treatment of pressure ul-
cers: a literature review. Wound Med 2017;16:
46–51.
12. Zhong Y, Cohen JT, Goates S, Luo M, Nelson J,
Neumann PJ. The cost-effectiveness of oral nu-
trition supplementation for malnourished older
hospital patients. Appl Health Econ Health Policy
2017;15:75–83.
13. Cereda E, Klersy C, Andreola M, et al. Cost-
effectiveness of a disease-specific oral nutritional
support for pressure ulcer healing. Clin Nutr 2017;
36:246–252.
14. Neyens JC, Cereda E, Rozsos I, et al. Effects of an
arginine-enriched oral nutritional supplement on the
healing of chronic wounds in non-malnourished pa-
tients; a multicenter case series from the Netherlands
and Hungary. J Gerontol Geriatr Res 2017;6:1–6.
15. Ellinger S. Micronutrients, arginine, and gluta-
mine: does supplementation provide an efficient
tool for prevention and treatment of different
kinds of wounds? Adv Wound Care (New Ro-
chelle) 2014;3:691–707.
16. Ogura Y, Yuki N, Sukegane A, et al. Treatment of
pressure ulcers in patients with declining renal
function using arginine, glutamine and ß-hydroxy-ß-
methylbutyrate. J Wound Care 2015;24:478–482.
17. Wong A, Chew A, Wang CM, Ong L, Zhang SH,
Young S. The use of a specialised amino acid mixture
for pressure ulcers: a placebo-controlled trial. J
Wound Care 2014;23:259–260, 262–264, 266–269.
18. Pouyssegur V, Brocker P, Schneider SM, et al. An
innovative solid oral nutritional supplement to fight
weight loss and anorexia: open, randomised con-
trolled trial of efficacy in institutionalised, malnour-
ished older adults. Age Ageing 2015;44:245–251.
19. Van Wymelbeke V, Brondel L, Bon F, Martin-
Pfitzenmeyer I, Manckoundia P. An innovative
brioche enriched in protein and energy improves
322
the nutritional status of malnourished nursing
home residents compared to oral nutritional sup-
plement and usual breakfast: farine+project. Clin
Nutr 2016;15:93–100.
20. Di Muzio M, Rosa F, Moriconi A. Nutrition in
dementia: a challenge for nurses. Prog Nutr 2018;
20:5–11.
21. Quain AM, Khardori NM. Nutrition in wound care
management: a comprehensive overview. Wounds
2015;27:327–335.
22. Rondinelli J, Zuniga S, Kipnis P, Kawar LN, Liu V,
Escobar GJ. Hospital-acquired pressure injury: risk-
adjusted comparisons in an integrated healthcare
delivery system. Nurs Res 2018;67:16–25.
23. The National Pressure Ulcer Advisory Panel. Pres-
sure injury prevention points. April 2016. www
.npuap.org/wp-content/uploads/2016/04/Pressure-
Injury-Prevention-Points-2016.pdf (last accessed May
13, 2019).
24. Saghaleini SH, Dehghan K, Shadvar K, Sanaie S,
Mahmoodpoor A, Ostadi K. Pressure ulcer and
nutrition. Indian J Crit Care Med 2018;22:283–289.
25. Citty SW, Kamel A, Garvan C, Marlowe L,
Westhoff L. Optimizing the electronic health re-
cord to standardize administration and documen-
tation of nutritional supplements. BMJ Qual
Improv Rep 2017;6:u212176.w4867.
26. Sriram K, Sulo S, VanDerBosch G, et al. A com-
prehensive nutrition-focused quality improvement
program reduces 30-day readmissions and length
of stay in hospitalized patients. JPEN J Parenter
Enteral Nutr 2017;41:384–391.
27. Soban LM, Finley EP, Miltner RS. Identifying pat-
terns in implementation of hospital pressure ulcer
prevention programs: a multisite qualitative study.
J Wound Ost Contin Nurs 2016;43:248–253.
28. Baute V, Sampath-Kumar R, Nelson S, Basil B.
Nutrition education for the health-care provider
improves patient outcomes. Glob Adv Health Med
2018;7:2164956118795995.
29. Ayello E. Nursing 2014 survey results: wound care
and prevention. Nursing 2014;44:32–40.
30. Kawasaki Y, Tamaura Y, Akamatsu R, Sakai M,
Fujiwara K. Factors associated with the practice
of nursing staff sharing information about pa-
tients’ nutritional status with their colleagues in
hospitals. Euro J Clin Nutr 2018;72:112–116.
31. Smith S, Chamblee T, Falder-Saeed K, et al.
Malnutrition in hospitalized adult patients: the
role of the clinical nurse specialist. Natl Assoc
Clin Nurse Specialists 2017;1–22.
32. Guenter P, Jensen G, Patel V, et al. Addressing
disease-related malnutrition in hospitalized pa-
CITTY ET AL.
tients: a call for a national goal. Jt Comm Qual
Patient Saf 2015;41:469–473.
33. The Joint Commission. Provision of care, treatment,
and services (PC) (Critical Access Hospitals/Critical
Access Hospitals). Nutritional and Functional
Screening–Requirement. 2018. https://www.joint
commission.org/standards_information/jcfaqdetails
.aspx?StandardsFAQId=1604&StandardsFAQChapterId
=29&ProgramId=0&ChapterId=0&IsFeatured=False&
IsNew=False&Keyword=nutrition (last accessed
May 13, 2019).
34. Heyland DK, Dhaliwal R, Jiang X, Day AG. Iden-
tifying critically ill patients who benefit the most
from nutrition therapy: the development and initial
validation of a novel risk assessment tool. Crit
Care 2011;15:R268.
35. Detsky AS, McLaughlin JR, Baker JP, et al. What is
subjective global assessment of nutritional status?
JPEN J Parenter Enteral Nutr 1987;11:8–13.
36. Bauer J, Capra S, Ferguson M. Use of the scored
Patient-Generated Subjective Global Assessment
(PG-SGA) as a nutrition assessment tool in patients
with cancer. Eur J Clin Nutr 2002;56:779–785.
37. Jensen GL, Cederholm T, Correia MI, et al. GLIM
criteria for the diagnosis of malnutrition: a consensus
report From the global clinical nutrition community.
JPEN J Parenter Enteral Nutr 2019;43:32–40.
38. Varghese J, Kleine M, Gessner SI, Sandmann S,
Dugas M. Effects of computerized decision sup-
port system implementations on patient outcomes
in inpatient care: a systematic review. J Am Med
Inform Assoc 2018;25:593–602.
39. Fossum M, Ehnfors M, Svensson E, Hansen LM,
Ehrenberg A. Effects of a computerized decision
support system on care planning for pressure ul-
cers and malnutrition in nursing homes: an inter-
vention study. Int J Med Inform 2013;82:911–921.
40. Kellett J, Kyle G, Itsiopoulos C, Naunton M, Luff
N. Malnutrition: the importance of identification,
documentation, and coding in the acute care
setting. J Nutri Metabol 2016;2016:9026098.
41. Elion J. Documenting malnutrition. For The Record
2014;26:26.
42. Institute of Medicine. Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cho-
lesterol, Protein, and Amino Acids. Washington, DC:
The National Academies of Press, 2002. https://
www.nap.edu/read/10490/chapter/1 (last accessed
May 13, 2019).
43. National Institutes of Health Office of Dietary Sup-
plements. Vitamin C fact sheet for health profes-
sionals. Updated September 18, 2018. https://ods
.od.nih.gov/factsheets/VitaminC-HealthProfessional
(last accessed May 13, 2019).
44. Molnar JA, Underdown MJ, Clark WA. Nutrition
and chronic wounds. Adv Wound Care 2014;3:
663–681.
45. Institute of Medicine (US) Panel on Micronutrients.
Dietary Reference Intakes for Vitamin A, Vitamin K,
Arsenic, Boron, Chromium, Copper, Iodine, Iron,
Manganese, Molybdenum, Nickel, Silicon, Vana-
dium, and Zinc. Washington, DC: National Acade-
mies Press, 2001. https://www.ncbi.nlm.nih.gov/
books/NBK222312 (last accessed May 13, 2019).
46. United States Food and Drug Administration. FDA
101: Dietary supplements. https://www.fda.gov/
ForConsumers/ConsumerUpdates/ucm050803.htm
Updated July 15, 2015. (last accessed April 25, 2019).
47. Meehan A, Beinlich N, Hammonds T. A nurse-
initiated perioperative pressure injury risk as-
sessment and prevention protocol. AORN J 2016;
104:554–565.
48. Barnsteiner J. Patient Safety and Quality: An
Evidence-Based Handbook for Nurses. Rockville, MD:
Agency for Healthcare Research and Quality, 2008.
https://www.ncbi.nlm.nih.gov/books/NBK2648. (last
accessed May 13, 2019).
49. van den Berg GH, Lindeboom R, van der Zwet WC.
The effects of the administration of oral nutri-
tional supplementation with medication rounds on
the achievement of nutritional goals: a random-
ized controlled trial. Clin Nutr 2015;34:15–19.
50. Gardiner P, Sadikova E, Filippelli AC, White LF,
Jack BW. Medical reconciliation of dietary sup-
plements: don’t ask, don’t tell. Patient Educ Couns
2015;98:512–517.
Abbreviations and Acronyms
AND ¼ Academy of Nutrition and Dietetics
ASPEN ¼ American Society for Parenteral
and Enteral Nutrition
CDSS ¼ computerized decision support
system
CI ¼ confidence interval
EHR ¼ electronic health record
EMAR ¼ electronic medication
administration record
ENAR ¼ electronic nutrition administration
record
HAPI ¼ hospital-acquired pressure injury
NCP ¼ nutrition care process
ONS ¼ oral nutritional supplement
OR ¼ odds ratio
PI ¼ pressure injury
QI ¼ quality improvement
RAE ¼ retinol activity equivalents
RDA ¼ recommended dietary allowance
UL ¼ upper limit